Provider Demographics
NPI:1912160433
Name:LEO WARREN MD PC
Entity Type:Organization
Organization Name:LEO WARREN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-821-2500
Mailing Address - Street 1:2638 HIGHWAY 109
Mailing Address - Street 2:101
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1161
Mailing Address - Country:US
Mailing Address - Phone:636-821-2500
Mailing Address - Fax:
Practice Address - Street 1:2638 HIGHWAY 109
Practice Address - Street 2:101
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1161
Practice Address - Country:US
Practice Address - Phone:636-821-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7N81305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG37533Medicare UPIN
MO000014224Medicare PIN